Common Knowledge About Pulmonary Nodules (Part 4)

This article follows the previous three. In Common Knowledge About Pulmonary Nodules (1), I introduced some basic knowledge about pulmonary nodules; in Common Knowledge About Pulmonary Nodules (2), I described some basic features of benign and malignant pulmonary nodules; in Common Knowledge About Pulmonary Nodules (3), I introduced common examination and diagnostic methods for pulmonary nodules. In this article, I will introduce the management measures after a pulmonary nodule is diagnosed.

After being diagnosed with a pulmonary nodule, what should one do? This is the question many people care about most.

First, we must know that a pulmonary nodule is not lung cancer. No matter which statistical method is used, clinically diagnosed pulmonary nodules show that over 90% are unrelated to lung cancer; most pulmonary nodules are benign lesions. So after being diagnosed with a pulmonary nodule, there is no need to feel too much pressure.

Of course, a very small number of pulmonary nodules may indeed be early canceration. So we cannot let our guard down either. Most small pulmonary nodules cannot be definitively characterized by doctors. Understanding the patient's disease history, lifestyle, and family genetic history in detail helps judge the nature of the pulmonary nodule more accurately.

For example, in someone with a previous lung infection, a small pulmonary nodule may be a scar left behind after infection. In someone with a history of pulmonary tuberculosis, a small pulmonary nodule may simply be a tuberculous nodule. Silicosis patients also have nodules in the lungs. Such nodules differ in nature from malignant nodules. But even so, the possibility that these patients' small pulmonary nodules are malignant cannot be completely ruled out. We can only judge that these patients' nodules are most likely benign, yet it is still necessary to repeat a chest CT once a year to observe changes.

The patient's lifestyle, living environment, and work environment are also reference factors for judging whether a pulmonary nodule is benign or malignant. If the patient smokes long-term, or has long-term exposure to asbestos, arsenic, beryllium, cadmium, coal smoke, or radon in living or occupational environments—that is, if their occupation involves chemical plants, coal mines, marble cutting, or they live long-term near such sites—then once a pulmonary nodule is diagnosed, heightened attention is needed, with periodic chest CT follow-up to observe changes.

Generally, for such patients we recommend a CT recheck every three months in the first year, then every six months thereafter, with five years of follow-up. If the nodule changes little during this period, CT can then be repeated once a year. If the nodule is absorbed during this period, such frequent follow-up is no longer needed. But given the high association between their occupation and lung cancer, after age forty, such individuals should include chest CT in their annual checkup.

If the patient has a family member with lung cancer or other tumors, or has personally had emphysema, chronic obstructive pulmonary disease, interstitial pneumonia, or other lung diseases, heightened attention is needed, because these are also high-risk factors for lung cancer.

Once such patients are diagnosed with a pulmonary nodule, regardless of nodule size or characteristics, they need follow-up every three months in the first year and then every six months thereafter. After five years of follow-up, if the nodule has been absorbed, follow-up may stop, or chest CT may be done once a year or every two years according to routine checkup rules. If the nodule shows no significant change, then chest CT should be repeated once a year.

If the patient has none of the above risk factors but has a part-solid nodule (part-solid nodule or mixed small nodule) larger than 5 mm, it can be classified as a high-risk nodule, with CT recheck every 3 months. Part-solid pulmonary nodules smaller than 5 mm also require recheck every six months, once a year, for five consecutive years. If the patient has multiple pulmonary nodules, recheck every 3 months, once a year, for five consecutive years.

Solid and ground-glass nodules smaller than 3 mm are basically benign and only need annual recheck. Solid nodules and pure ground-glass nodules larger than 5 mm require recheck every six months for five consecutive years. Pulmonary nodules larger than 10 mm should be examined by combining bronchoscopy with chest CT and chest MRI, plus needle biopsy or surgical resection, followed by postoperative pathology. If economic conditions allow, genetic testing and PET-CT can be considered to determine whether there is metastasis to other organs throughout the body and whether detectable gene mutations exist, providing a scientific basis for further drug treatment.

The above examinations can all be performed together with tumor marker testing for lung cancer. If tumor markers are abnormal, surgical resection should be considered, and postoperative pathology determines the nature of the nodule. If a certain type of lung cancer is confirmed, treatment is carried out according to the relevant guidelines.

In principle, for the general population, pulmonary nodules larger than 10 mm, and for high-risk groups, nodules larger than 8 mm, should be considered for surgical resection or ablation. Postoperative pathology determines the nature of the nodule; if it is malignant nodule, subsequent treatment follows the treatment standards for lung cancer.

Usually, small nodules are treated with minimally invasive thoracoscopic surgery. This surgery is less invasive with fewer aftereffects, and patients can usually be discharged after only about a week in hospital, though some patients do have aftereffects such as postoperative pain. Ablation has an even smaller wound and fewer side effects, but I have seen some patients after ablation who also suffered severe aftereffects—long-term pain and discomfort that did not ease for years.

After surgery for a small pulmonary nodule, patients should not engage in vigorous exercise, because postoperative lung function is always affected to some degree. For subsequent fitness exercise, relatively gentle activities such as Tai Chi and Baduanjin are recommended. Diet should also be light; moderate amounts of high-protein food are fine, but spicy and irritating foods should be avoided. After surgery, follow the doctor's orders and have periodic reexaminations to prevent recurrence.

Whether tiny pulmonary nodules should be treated has always been highly controversial: some doctors advocate treatment, while others advocate no treatment and periodic observation. Personally, I think moderate treatment is better. After all, a small pulmonary nodule is like a time bomb—it can turn malignant at any time.

For patients with signs of infection, anti-infective treatment is given and the pulmonary nodule is usually absorbed. For refractory small pulmonary nodules, Western medicine may have few options, but Chinese herbs that activate blood and resolve stasis, soften hardness and dissipate nodules, and resolve phlegm and dissipate nodules have a certain therapeutic effect on small pulmonary nodules and can eliminate them in some patients.